What is the management plan for a knee sprain?

Knee Sprain Management

For knee sprains, implement immediate functional treatment with early weight-bearing as tolerated, combined with a lace-up or semi-rigid brace for 4-6 weeks and supervised exercise therapy starting within 48-72 hours, while avoiding prolonged immobilization beyond initial pain control.

Initial Management (First 24-72 Hours)

Functional Support Over Immobilization

• Apply a lace-up or semi-rigid brace within the first 48 hours and continue for 4-6 weeks, as functional support is superior to immobilization and leads to faster return to sports (4.6 days sooner) and work (7.1 days sooner) 1
• Begin weight-bearing immediately as tolerated, avoiding only activities that cause pain 1
• Limit immobilization to no more than 3-5 days and only for initial pain control, as prolonged immobilization causes decreased range of motion, chronic pain, and joint instability without any demonstrated benefits 1, 2

Acute Symptom Management

• Apply ice (ice and water in a bag surrounded by damp cloth) for 20-30 minutes per application to reduce pain and swelling, avoiding direct skin contact to prevent cold injury 1
• Use compression wraps to promote comfort, ensuring circulation is not compromised 1
• Note: RICE protocol alone has no positive influence on pain, swelling, or patient function and should not be relied upon as sole treatment 1, 2

Pain Control

• Prescribe NSAIDs (ibuprofen, naproxen, diclofenac, or celecoxib) for short-term use (<14 days) to reduce pain and swelling, which accelerates return to activity 1, 2
• Acetaminophen is equally effective as NSAIDs for pain, swelling, and range of motion if NSAIDs are contraindicated 1, 2
• Avoid opioid analgesics, as they provide no better pain relief than NSAIDs but cause significantly more side effects 1, 2

Rehabilitation Protocol (Starting 48-72 Hours Post-Injury)

Supervised Exercise Therapy (Level 1 Evidence)

• Begin supervised exercise therapy within 48-72 hours after injury, as this has the strongest evidence (Level 1) for effectiveness and is superior to non-supervised home exercises 1, 2
• Include the following components in a structured program:
  • Range of motion exercises: Start with gentle flexion and extension multiple times daily to maintain joint mobility 1
  • Proprioception training: Critical to prevent recurrent sprains, especially after previous injuries 1
  • Strengthening exercises: Focus on quadriceps and hamstring strengthening using both isometric and isokinetic exercises 1, 3
  • Coordination and functional exercises: Progress to sport-specific movements as tolerated 1

Rehabilitation Principles

• Start with levels of exercise within the individual's capability, building up the "dose" sensibly over several months 4
• Link exercise regimens to daily activities (e.g., before morning shower or meals) so they become part of lifestyle 4
• Use "small amounts often" (pacing) as with other activities 4

Manual Therapy Adjunct

• Manual mobilization can be added to enhance treatment effects but should never be used alone—always combine with exercise therapy 4, 1

Return to Activity Timeline

Mild Knee Sprains

• Return to mostly sitting work at 2 weeks 1
• Full return to work and sports at 3-4 weeks depending on task requirements 1

Moderate to Severe Knee Sprains

• Return to sedentary work at 3-4 weeks 1
• Full return to work and sports at 6-8 weeks depending on physiotherapy results 1

Criteria for Return

• Pain-free active range of motion achieved 5
• Strength restored (minimal deficit of 4% in extension and 2% in flexion is acceptable) 3
• Joint stability without support 5

Prevention of Recurrent Injury

Ongoing Exercise Program

• Incorporate ongoing ankle and knee exercises into regular training activities to prevent recurrence, as this has high cost-benefit ratios due to reduced recurrence rates 1
• Continue proprioception training as part of regular athletic training 1

Continued Bracing

• Continue ankle/knee bracing during high-risk activities even after recovery 1
• For prevention, both tape and brace may be used, with choice based on patient preferences 4

Critical Pitfalls to Avoid

Immobilization Errors

• Do not immobilize beyond 3-5 days, as this leads to worse functional outcomes including decreased range of motion, chronic pain, and joint instability 1, 2
• Prolonged immobilization shows no benefits compared to functional treatment 4

Inadequate Rehabilitation

• Inadequate treatment leads to chronic problems such as decreased range of motion, pain, and joint instability 1
• Strength deficits are systematically greater at higher speeds of isokinetic movement, so rehabilitation must include high-speed extension and flexion exercises 3

Medication Misuse

• NSAIDs may delay natural healing as inflammation is necessary for tissue recovery—limit use to <14 days 2
• Never prescribe opioids for knee sprains due to significantly more side effects without superior pain relief 1, 2

Special Considerations

Assessment Timing

• Re-examine 3-5 days after injury for accurate diagnosis and treatment planning, as clinical assessment of ligament damage is optimized when swelling has decreased 1

Severe Injuries Requiring Surgical Consideration

• Athletic patients with complete ligament ruptures should be offered the option of surgical reconstruction 6
• Knee dislocations, fractures, and extensive soft tissue injury require immediate and thoughtful treatment 7
• Misdiagnosed lesions often do not heal optimally and induce new traumas synonymous of functional impairment and handicap 8